madman
Super Moderator
Abstract
Introduction: Patients with Peyronie’s disease may experience significant distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity, and direction of the curvature, penile length, and the quality of erectile function.
Aim: To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.
Methods: MEDLINE, Google Scholar, and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective, and retrospective studies.
Main Outcome Measure: The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/ excision and grafting in order to identify an ideal graft has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.
Results: In order to allow shared decision-making, patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.
Conclusions: Current European Society for Sexual Medicine recommendations covers several aspects of Peyronie’s disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways.
INTRODUCTION
Peyronie’s disease (PD) (Iduratio Penis Plastica) has been described in the literature as early as the 1500s. It is noted in the works of the famous Italian anatomist Gabriel Fallopius, a pioneer in reproductive organs as well as by Andreas Vesalius, a 16th century Dutch Physician and author of one of the most influential books on Human anatomy De Humani Corporis Fabrica Libri Septem (On the Fabric of the Human Body).1 It was not until 1743, that Francois de la Peyronie, a surgeon of the Court of King Louise XV in France, outlined the disease in detail.2
PD is an acquired connective tissue disorder that is associated with the formation of fibrous/calcified inelastic plaques at the level of the tunica albuginea (TA) of the penis.3,4 The exact etiology of PD is unknown. The most accepted hypothesis is that in genetically prone individuals, trauma or repetitive microtrauma to the erect penis causes inflammation, degradation of the elastic fibers, and fibrin deposition.5−7 This scarring process may lead to a variety of issues, including penile deformity and erectile dysfunction. Consequently, men with PD may experience significant distress; the extent of which does not necessarily correlate with the degree of curvature nor penile deformity. Psychological concerns regarding self-image, sexual appearance and sexual performance, low self-esteem, anxiety, depression, and relationship problems may then further contribute to the psychogenic component of erectile dysfunction (ED).8−10
Recent reports have shown that the prevalence of PD may be as high as 9%, but the true prevalence may be underreported.11 PD is associated with conditions including diabetes, hypertension, hyperlipidemia, ED, smoking, and excessive alcohol consumption. It may also be present following local trauma or surgery such as radical prostatectomy.12−15 The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity, and direction of the curvature, penile length, and the quality of erectile function.11
In the early/acute stage of PD, non-surgical treatments aim to alleviate penile pain and minimize disease progression with stabilization of inflammation, plaque formation, and penile deformity.16 In the late/chronic phase, surgical treatments may be required. These procedures include both penile shortening and penile lengthening types. Surgery aims to correct the curvature whilst maintaining satisfactory penile length and rigidity to enable penetrative sexual activity. Possible risks of surgery include penile shortening, ED, glans hypoaesthesia, residual or recurrent curvature, and palpable or uncomfortable suture knots below the skin.11 To date, penile straightening surgery represents the gold standard for the correction of penile deformity, with subsequent relief of sexual distress.
The aim of this paper is to review the current evidence of surgical treatments for PD and provide official position statements with a series of guiding statements to manage patients’ expectations and their clinical issues, on behalf of the European Society for Sexual Medicine (ESSM).
PATIENT EXPECTATIONS
Statement #1: The treating clinician should adequately counsel patients before surgery. Benefits, as well as side effects and complications of each surgical treatment, should be discussed in detail with the patient to set realistic expectations towards surgical outcomes (Good clinical practice).
Statement #2: The treating clinician should thoroughly address psychological, emotional, and relationship issues attributable to PD (Level 4, Grade C).
*Evidence
*Remark
INDICATIONS FOR SURGICAL TREATMENT
General Considerations
Statement #3: Surgical treatment should only be performed in PD patients when the curvature and/or penile deformity and/or inadequate quality of erections do not allow satisfactory sexual intercourse, or when the deformity causes severe bother (Level 3, Grade C).
Statement #4: Surgery should only be performed in patients with stable disease for at least six to twelve months (Level 3, Grade C).
Statement #5: In penile surgery for PD, when adopting a subcoronal approach, circumcision is not necessary for selected patients with a normal, elastic prepuce (Level 3, Grade C).
*Evidence
Tunical Plication (Shortening Procedures)
Statement #6: Tunical plication can be offered to reduce penile curvature in patients with PD (Level 3, Grade C).
*Evidence
*Remark
Grafting Procedures
Statement #7: Grafting techniques can be offered to improve penile curvature and correct penile deformity in selected patients with PD including those with preservation of erectile quality, a curvature of more than 60 degrees, ossified plaque, significant waist deformity, or when plication surgery may potentially cause loss of more than 20% of the overall penile length (Level 3, Grade C).
Statement #8: The use of DacronTM and Gore-TexTM for grafting in penile surgery for PD should be strongly discouraged (Level 3, Grade C).
*Evidence
*Remark
Penile Prosthesis
Statement #9: Penile prosthesis implantation is reserved for PD patients with refractory ED or distal flaccidity not responding to pharmacologic treatment or those with complex deformities that would otherwise require PIG/PEG procedures (Level 3, Grade C).
Statement #10: Additional procedures including modeling, tunical plication, plaque incision/excision, and/or grafting are performed when penile deformity and/or penile curvature persist following penile prosthesis implantation (Level 3, Grade C).
Statement #11: Inflatable prostheses are associated with superior results in terms of curvature correction, rigidity, girth restoration, and concealability than their semirigid counterpart in patients with PD (Level 4, Grade C).
*Evidence
*Remark
POSTOPERATIVE COMPLICATIONS
Statement #12: In select cases, complications may be managed successfully with revision surgery, including delayed PP implantation in patients who have developed de novo refractory ED. (Level 4, Grade C).
*Evidence
-De Novo ED
-Residual or Recurrent Curvature (ReC)
-Glans Hypoesthesia
-Palpable or Uncomfortable Sutures and Graft
-Bulge/Ballooning or Indentation Deformities
*Remark
DIFFICULT SALVAGE CASES: MANAGEMENT OF RECURRENT DEVIATION FOLLOWING PLICATION, GRAFTING, OR INTRALESIONAL INJECTION TREATMENTS
Statement #13: None of the straightening procedures currently available has proven superior with regards to preventing curvature recurrence (Level 3, Grade C)
Statement #14: Surgical curvature correction after Collagenase Clostridium Histolyticum (CCH) injection is possible without a significant increase in postoperative complications (Level 4, Grade C)
Statement #15: Postoperative rehabilitation programs may reduce the risk of penile curvature recurrence and shortening (Level 4, Grade C)
Statement #16: When necessary, the revision surgery should be carried out at least 6 months after the initial procedure to allow for complete healing and stabilization of the deformity and for adequate assessment of postoperative erectile function (Level 4, Grade C)
Statement #17: Penile prosthesis implantation alone or in combination with straightening maneuvers can be considered during revision surgery, in order to minimize further penile length loss or to avoid worsening of erectile function (Level 4, Grade C)
*Evidence
CONCLUSIONS
Although surgery represents the gold standard treatment of PD, it remains far from perfect, despite numerous technique modifications, development of various grafts, and rehabilitation protocols. The main surgical limitation is that it does not repair the damage produced by PD and may not completely restore the penis to its original dimensions and function. Current literature lacks large volumes of prospective series, hindering our ability to scientifically compare the techniques and their outcomes.
A multinational, multicenter prospective registry of PD surgery procedures may contribute to the evidence-based knowledge on the indications, procedures, and possible complications of PD treatment modalities.
Introduction: Patients with Peyronie’s disease may experience significant distress. The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity, and direction of the curvature, penile length, and the quality of erectile function.
Aim: To review the evidence associated with surgical treatment of Peyronie`s Disease and provide clinical recommendations on behalf of the European Society for Sexual Medicine. 131 peer-reviewed studies and systematic reviews, which were published from 2009 to 2019 in the English language, were included.
Methods: MEDLINE, Google Scholar, and EMBASE were searched for randomized clinical trials, meta-analyses, open-label prospective, and retrospective studies.
Main Outcome Measure: The panel provided statements on clinically relevant questions including patient involvement in the decision process, indications for surgery, choice of the approach, and the management of patient expectations. A comparison of the different grafts used in patients who have undergone plaque incision/ excision and grafting in order to identify an ideal graft has been carried out. The prevalence of postoperative complications has been summarized. Levels of evidence were provided according to the Oxford 2011 criteria and Oxford Centre for Evidence-Based Medicine recommendations.
Results: In order to allow shared decision-making, patient preoperative counselling regarding the pros and cons of each intervention is recommended. In particular, adverse effects of surgical treatments should be discussed to set realistic understanding and expectations of surgical outcomes and ultimately improve postoperative satisfaction rates. Surgical treatment should be only offered in the chronic phase of the condition, when the deformity and/or degree of erectile dysfunction, prevent patients from engaging in satisfying sexual interaction, or if the deformity is the cause of severe bother.
Conclusions: Current European Society for Sexual Medicine recommendations covers several aspects of Peyronie’s disease treatment. These recommendations aim both to ensure patients and partners have accurate and realistic expectations of their treatment options, as well as to formulate algorithms to guide clinician management pathways.
INTRODUCTION
Peyronie’s disease (PD) (Iduratio Penis Plastica) has been described in the literature as early as the 1500s. It is noted in the works of the famous Italian anatomist Gabriel Fallopius, a pioneer in reproductive organs as well as by Andreas Vesalius, a 16th century Dutch Physician and author of one of the most influential books on Human anatomy De Humani Corporis Fabrica Libri Septem (On the Fabric of the Human Body).1 It was not until 1743, that Francois de la Peyronie, a surgeon of the Court of King Louise XV in France, outlined the disease in detail.2
PD is an acquired connective tissue disorder that is associated with the formation of fibrous/calcified inelastic plaques at the level of the tunica albuginea (TA) of the penis.3,4 The exact etiology of PD is unknown. The most accepted hypothesis is that in genetically prone individuals, trauma or repetitive microtrauma to the erect penis causes inflammation, degradation of the elastic fibers, and fibrin deposition.5−7 This scarring process may lead to a variety of issues, including penile deformity and erectile dysfunction. Consequently, men with PD may experience significant distress; the extent of which does not necessarily correlate with the degree of curvature nor penile deformity. Psychological concerns regarding self-image, sexual appearance and sexual performance, low self-esteem, anxiety, depression, and relationship problems may then further contribute to the psychogenic component of erectile dysfunction (ED).8−10
Recent reports have shown that the prevalence of PD may be as high as 9%, but the true prevalence may be underreported.11 PD is associated with conditions including diabetes, hypertension, hyperlipidemia, ED, smoking, and excessive alcohol consumption. It may also be present following local trauma or surgery such as radical prostatectomy.12−15 The choice of treatment depends on a variety of factors, including the stage of the disease, the presence of pain, severity, and direction of the curvature, penile length, and the quality of erectile function.11
In the early/acute stage of PD, non-surgical treatments aim to alleviate penile pain and minimize disease progression with stabilization of inflammation, plaque formation, and penile deformity.16 In the late/chronic phase, surgical treatments may be required. These procedures include both penile shortening and penile lengthening types. Surgery aims to correct the curvature whilst maintaining satisfactory penile length and rigidity to enable penetrative sexual activity. Possible risks of surgery include penile shortening, ED, glans hypoaesthesia, residual or recurrent curvature, and palpable or uncomfortable suture knots below the skin.11 To date, penile straightening surgery represents the gold standard for the correction of penile deformity, with subsequent relief of sexual distress.
The aim of this paper is to review the current evidence of surgical treatments for PD and provide official position statements with a series of guiding statements to manage patients’ expectations and their clinical issues, on behalf of the European Society for Sexual Medicine (ESSM).
PATIENT EXPECTATIONS
Statement #1: The treating clinician should adequately counsel patients before surgery. Benefits, as well as side effects and complications of each surgical treatment, should be discussed in detail with the patient to set realistic expectations towards surgical outcomes (Good clinical practice).
Statement #2: The treating clinician should thoroughly address psychological, emotional, and relationship issues attributable to PD (Level 4, Grade C).
*Evidence
*Remark
INDICATIONS FOR SURGICAL TREATMENT
General Considerations
Statement #3: Surgical treatment should only be performed in PD patients when the curvature and/or penile deformity and/or inadequate quality of erections do not allow satisfactory sexual intercourse, or when the deformity causes severe bother (Level 3, Grade C).
Statement #4: Surgery should only be performed in patients with stable disease for at least six to twelve months (Level 3, Grade C).
Statement #5: In penile surgery for PD, when adopting a subcoronal approach, circumcision is not necessary for selected patients with a normal, elastic prepuce (Level 3, Grade C).
*Evidence
Tunical Plication (Shortening Procedures)
Statement #6: Tunical plication can be offered to reduce penile curvature in patients with PD (Level 3, Grade C).
*Evidence
*Remark
Grafting Procedures
Statement #7: Grafting techniques can be offered to improve penile curvature and correct penile deformity in selected patients with PD including those with preservation of erectile quality, a curvature of more than 60 degrees, ossified plaque, significant waist deformity, or when plication surgery may potentially cause loss of more than 20% of the overall penile length (Level 3, Grade C).
Statement #8: The use of DacronTM and Gore-TexTM for grafting in penile surgery for PD should be strongly discouraged (Level 3, Grade C).
*Evidence
*Remark
Penile Prosthesis
Statement #9: Penile prosthesis implantation is reserved for PD patients with refractory ED or distal flaccidity not responding to pharmacologic treatment or those with complex deformities that would otherwise require PIG/PEG procedures (Level 3, Grade C).
Statement #10: Additional procedures including modeling, tunical plication, plaque incision/excision, and/or grafting are performed when penile deformity and/or penile curvature persist following penile prosthesis implantation (Level 3, Grade C).
Statement #11: Inflatable prostheses are associated with superior results in terms of curvature correction, rigidity, girth restoration, and concealability than their semirigid counterpart in patients with PD (Level 4, Grade C).
*Evidence
*Remark
POSTOPERATIVE COMPLICATIONS
Statement #12: In select cases, complications may be managed successfully with revision surgery, including delayed PP implantation in patients who have developed de novo refractory ED. (Level 4, Grade C).
*Evidence
-De Novo ED
-Residual or Recurrent Curvature (ReC)
-Glans Hypoesthesia
-Palpable or Uncomfortable Sutures and Graft
-Bulge/Ballooning or Indentation Deformities
*Remark
DIFFICULT SALVAGE CASES: MANAGEMENT OF RECURRENT DEVIATION FOLLOWING PLICATION, GRAFTING, OR INTRALESIONAL INJECTION TREATMENTS
Statement #13: None of the straightening procedures currently available has proven superior with regards to preventing curvature recurrence (Level 3, Grade C)
Statement #14: Surgical curvature correction after Collagenase Clostridium Histolyticum (CCH) injection is possible without a significant increase in postoperative complications (Level 4, Grade C)
Statement #15: Postoperative rehabilitation programs may reduce the risk of penile curvature recurrence and shortening (Level 4, Grade C)
Statement #16: When necessary, the revision surgery should be carried out at least 6 months after the initial procedure to allow for complete healing and stabilization of the deformity and for adequate assessment of postoperative erectile function (Level 4, Grade C)
Statement #17: Penile prosthesis implantation alone or in combination with straightening maneuvers can be considered during revision surgery, in order to minimize further penile length loss or to avoid worsening of erectile function (Level 4, Grade C)
*Evidence
CONCLUSIONS
Although surgery represents the gold standard treatment of PD, it remains far from perfect, despite numerous technique modifications, development of various grafts, and rehabilitation protocols. The main surgical limitation is that it does not repair the damage produced by PD and may not completely restore the penis to its original dimensions and function. Current literature lacks large volumes of prospective series, hindering our ability to scientifically compare the techniques and their outcomes.
A multinational, multicenter prospective registry of PD surgery procedures may contribute to the evidence-based knowledge on the indications, procedures, and possible complications of PD treatment modalities.
